As the fate of the Affordable Care Act remains uncertain, some of Milwaukee’s top health care leaders are voicing concern with what changes at both the federal and state levels could mean for patients and providers.
A panel of local health care representatives recently convened for a Public Policy Forum discussion on the Affordable Care Act and Medicaid reform, during which they weighed in on two topics that will have major implications for their industry.
Throughout the discussion – held the day before the U.S. House of Representatives passed a measure to repeal and replace the ACA – one message resounded: the uncertainty of action or inaction by Congress on health care, along with the possibility of Gov. Scott Walker’s Medicaid reform plan, add layers of challenge to an industry that already faces many.
“I have a feeling you’re waiting for me to give you the secret as to what’s happening in D.C. in terms of affordable health care,” said Wisconsin Department of Health Services secretary Linda Seemeyer, addressing the forum audience. “I don’t have the secret. I think we’re all just watching and seeing.”
Catherine Jacobson, president and chief executive officer of Froedtert Health and chair of the Wisconsin Hospital Association, praised the expansion of health care coverage in Wisconsin since the ACA was enacted.
“One of the biggest benefits we’ve seen as providers is the expansion in coverage,” Jacobson said. “The Affordable Care Act really wasn’t about cost and affording, but it was about coverage and it was about expansion. And we in Wisconsin did it in a unique way that was incredibly effective.”
While Wisconsin refused the ACA’s Medicaid expansion, the state chose to cover all childless adults who are under the poverty level, which has widened coverage to 130,000 more people.
Meanwhile, about 239,000 residents have signed up for coverage on the public insurance exchange in 2017, with 84 percent of them receiving federal tax credits to help cover their costs, according to the U.S. Department of Health and Human Services.
Jacobson said any federal reform effort should recognize Wisconsin’s model for Medicaid expansion with funding.
She raised concerns with the proposed elimination of the ACA’s subsidies for people who buy insurance through the marketplace. The American Health Care Act, which narrowly passed through the House on May 4, would instead provide tax credits to help people pay for health insurance.
“We’re missing the big picture on health care reform… it is absolutely critical that we keep patients at the center of the discussion,”
– Nick Turkal, President and CEO, Aurora Health Care
“It might sound like a tweak – a premium subsidy versus a tax credit,” Jacobson said. “… (But) the difficulty in getting it and filing it for every single one of those people who falls off the exchanges, there’s no place else to go. I mean, they’re out. That’s the ramification of that.”
Also a concern for some is the American Health Care Act’s provision giving states the option of allowing insurers to charge people more for pre-existing conditions.
Peggy Troy, president and CEO of Children’s Hospital of Wisconsin, came out against the bill after it passed through the House.
“As the region’s only independent health care system dedicated solely to the health and wellbeing of children, we are disappointed that the American Health Care Act passed the House,” Troy said in a prepared statement. “The bill fails to appropriately safeguard Medicaid funding, coverage and benefits for children and families. We will continue to advocate for the Senate to improve the bill so that Medicaid funding for kids is protected and minimum benefit protections are maintained. Any bill must support what Wisconsin has done to offer high-quality and affordable health care.”
In an interview with BizTimes, Aurora Health Care president and CEO Nick Turkal noted that, historically, successful health care legislation has enjoyed bipartisan support, but the current divisiveness in Congress precludes that.
“My belief is that at the national level we’re missing the big picture on health care reform, and that it is absolutely critical that we keep patients at the center of the discussion,” Turkal said. “When we talk about what success is in health care reform, we need to be saying, ‘How does it affect patients? How does it affect coverage? How does it affect access? And how does it affect their cost?’ And I think that’s gotten lost in what’s become a very partisan debate.”
Panelists at the Public Policy Forum discussion echoed those concerns, saying the debate over coverage has overshadowed other important health care conversations. Coverage, they said, doesn’t necessarily mean everyone has access to health care.
Health care leaders stressed that social determinants of health – factors such as transportation, housing, education and employment – cause significant barriers to patients accessing the health care system.
“If we don’t address that and other social determinants of health, you’re going to continue to pay for it,” Jacobson said. “It’s going to express itself in utilization of the health care system.”
Meanwhile, a proposal from Gov. Scott Walker’s office to alter Medicaid requirements has also drawn criticism.
Walker is currently seeking a waiver from the federal Centers for Medicare and Medicaid Services which would allow the state to implement several Medicaid policy changes, including establishing monthly premiums, limiting eligibility to 48 months and requiring drug screenings for childless adults.
Seemeyer said the state is submitting its waiver request this month, with possible implementation of the new requirements as early as 2019.
While the new policies have been “characterized as a radical proposal,” Seemeyer contended they are reasonable and will encourage people to find employment.
“People can do this if they want to do this,” she said.
The idea behind requiring Medicaid recipients to pay premiums – which would range from $1 to $10 – is more philosophical than financial.
“We think it’s important for people to have a little skin in the game,” she said. “And we think that people paying premiums starts people off on maybe a more responsible path.”
But health care leaders are quick to raise concerns.
While Jacobson said she understood the philosophy behind such requirements, the ramifications of a Medicaid recipient failing to meet them are too severe.
“If somebody doesn’t manage to get their $2 in, they lose coverage,” Jacobson said. “So what happens when they have an issue? They end up in our emergency room and they have no coverage.”
Bevan Baker, commissioner for the Milwaukee Health Department, said drug screenings would introduce more barriers to people getting the help they need.
“We are dealing with the most fragile part of human existence – the ability for a person to overcome addiction – and we’re going to now say we’re going to give you this hurdle,” Baker said. “I just think that’s a difficult thing. I think we need to be worried about what this does to our ecosystem.”
Seemeyer said the proposal comes in response to the state’s opioid crisis and could help those struggling with addiction. Under the plan, someone who tests positive for drugs could enroll in Medicaid and would be referred to a treatment program.
Julie Schuller, president and CEO of Sixteenth Street Community Health Centers, said the implications of these changes – both the ACA repeal and Medicaid reform – must be carefully weighed.
“I think that the system as a whole is very fragile,” Schuller said. “…So as we look at the (Medicaid) waiver being proposed or ACA, or the (American Health Care Act passed by the House), I think very small changes in the way that a payment is made to the system as a whole could have very dramatic effects for those of us with boots on the ground or for patients or people. So we need to be very careful that the tweaks we make don’t have such dramatic impacts on a very fragile system.”